Sunday, May 11, 2008

Consumer-Driven Healthcare

God forbid we call it "Patient-Driven Healthcare." At least that might make some sense.

But "Consumer-Driven Healthcare" seems to be what all the buzz is about. Learn which hospital is the highest "rated." Learn which hospitals do which procedures. Learn which hospitals give aspirin to 100% of their acute heart attack victims, or wash their hands, or have saunas and spas, or reiki, or DaVinci robots. With that Great Website out there, "consumers" are gonna have it all! Can't you hear it? "Our website will have a HUGE impact on where you'll get your care. Our website will have all of the information right at your fingertips as your clutching your chest and can't breathe! Our website will even tell you where the most non-foreign trained medical doctors are on staff and how many are board certified, and where those doctors trained - for we tap into a repository of 8,000 databases and cull the data that looks best to us! We'll even let you see how many gold stars they've paid qualified for!"

And the Average Joe (or Janet) Everyman LOVES this empowerment. I mean, what's not to like? Isn't it great? "I'm gonna know everything before I get to the hospital - and what I don't know, hell, I'm just going to look it up on the Great Website!"

What a crock of excrement.

What Joe and Janet don't realize is this: they're patients, not consumers.

If they were real consumers, they'd know what it costs to have a gallbladder removed, or what their surgeon will charge and how much he's willing to accept in payment for his services. They'd be able to talk directly to their doctor about pre-arranged fees for procedures, especially if they had no insurance. They'd have a way to negotiate with a hospital and show them the costs at other hospitals in the area. They'd also know what a hospital room, or ICU room, or operating-room-by-the-minute or Tylenol costs. And if they didn't want to pay the cost of a Tylenol, they'd be able to bring their own. But you see, that would not allow the hospital to pay for the electricity, and janitors, and cooking staff, and security force, and hoards of quality assurance coordinators and data gatherers.

Here's the newsflash: most Big Corporations are the "consumers." They buy insurance policies for many, many, many individuals. They're whom the financial and insurance industry lends an ear, not the individual patients themselves (although this might be changing slowly as more people aren't insured). And this Big Business "Consumer-Driven Healthcare" bus is being driven into your living room and computer console without a shred of evidence that it impacts (on a large scale) where patients receive their care. Here's the deal: most people go to the hospital facility closest to them. Period. They want to be near friends and family.

So all this marketing hype about "consumer-driven healthcare" means nothing - especially if you're going to try to figure out what it's going to cost you (versus your insurer) for a particular medical service. Like some asinine $5.2 million dollar website is going to make that happen?

Now I'm not saying that all the information on the web is necessarily bad. On the contrary. I firmly believe that the information on the web is helpful - even lifesaving - on occasion (can you say "Dr. Google?") Heck, just this week a neighbor of mine gradually had increasing right lower quadrant discomfort and Googled their symptoms and it suggested "appendicitis" - the correct diagnosis - prompting this individual to seek ER evaluation early. Forums and web-based support groups also can be remarkably helpful on a whole other level: they're the power of community.

But I only need to look at myself and the difficulty I have in determining who is a good doctor or a fantastic doctor, and realize even I - one working every day in the healthcare world - have a tough time telling who's okay, good, or great. That's because I don't work with dermatologists every day, or neurologists, or pathologists, or oncologists, or pulmonologists or urologists. Now I can tell you who'd I recommend as a reasonable internist (since I work with them more often), but most of them might not go to the hospital anymore, so how good is that recommendation, eh? You'll probably get whatever hospitalist is covering the ward that week when you come in sick. Good luck finding that person's credentials or being able to pick who's covering. And nursing coverage? You know, that all-important nurse-to-patient ratio that determines the real quality of care? Since your likely to know which ward you'll be admitted to, that information is irrelevant too.

There is also the issue that the things that truly make a doctor get better results are not and probably never will be effectively measured. I've stopped recommending specialists to family because they inevitably complain about them. Basically, they want Marcus Welby to pat them on the shoulder for an hour and if he still treats URIs with z-packs, so much the better. Insurers and the government want a robot who dispenses aspirin 100% of the time in less than 12.7 minutes and if the patient actually had GERD, well, at least the target was met.

I want the guy who's a workaholic, who reads 10 journals a month, always tracks down lab results and spends as long as it takes getting it right. The fact that this guy often has the personality skills of a rutabaga is perfectly cool; I'll handle the small talk, he can handle the medicine.

You are right in many things. I believe health care is very specific product and we can't compare it to selling cars or plasma TVs (and I say this, despite dealing health and life insurance in Canada). If you have universal health care, like we have, you usually have right to choose your doctor. And of course, some of them are better, some not. And everybody wants the best one. That creates place for bribes and similar things. On the other hand, there has to be some pressure for quality...

I know what you're saying, Wes, but I don't think that all websites should be lumped into the excrement bucket. :) Like it or not, our poor patients are going to have access to fewer and fewer resources - and anything we can do to help them successfully navigate the "system" is quite useful.

I'm working hard to make Revolution Health a meaningful site with enlightening information that is actionable and combined with online communities that stimulate measurable behavior modification. We should not shy away from using online tools to help people - let's harness the power of the Internet to affect real change. I agree that putting up a list of best doctors (paid for by those same doctors) is unhelpful and perhaps even unethical. But there's lots more to the "consumer-directed" movement that's positive... I have 1900 people in my weight loss group for example, and every day I get up and try to practice what I preach in that area.

Also, check out the momScore that we built - it's the first-of-its- kind analysis of maternal health quality indexes. I hope that moms across America will use the information to pressure their states to do a better job of caring for moms and babies. Knowledge is power - and I do think that these kinds of initiatives are real and useful.

Well, 'anonymous', I DO want Dr. Welby. If you recall, Dr. Welby was a superb diagnostician. He knew his patients. He didn't rely only on 'reams of tests' that prove... what? when so many false negatives/positives or just plain incorrect results are provided?

You can keep your 10 journal a month hyperactive whiz-kid that has no emphathy, no personal skills. Most of the crap published in journals is misleading at best and the unibiquitous 'meta data' studies, which are completely useless.

I want a guy I can feel comfortable telling that the pain is kind of all around my upper right quadrant... And not feel that all he is thinking about is the patient in the next room, and the one after that... I don't like 'inconveniencing' people, and I think that is true of a lot of us 'patients' out here.

God forbid the state gives that $5.2 million to hopitals to pay for things like nurses. Or uses it to pay for vaccines or other primary care needs of the poor using the ER as a clnic. Or for loan repayment to attract rpimary care docs to physician shortage areas.

I am a bit concerned about the negative comments about patients. I am sure some of us are unrealistic pains in the butt. Others of us have had bad experiences with doctors and hospitals and are trying to get decent medical care. We don't have the knowledge assess physicians or hospitals ourselves before we experience them - which feels like (and sometimes is) being a the mercy of strangers and a medical machine (the hospital) when we are most vulnerable.

Please remember that for every doctor story there is a patient story.

Patient's medical expectations are shaped by their experiences, which includes advertising. Someone has to educate patients on effective treatments (including behavioral changes) and what the likely outcome of an 'easier' treatment will be. That someone is usually nurses, patient educators, and physicians. Pointing the finger at patients' expectations is like pointing the finger at an illiterate student who was promoted through high school. Physicians themselves may support the 'easy fix' by giving drugs rather than dealing with underlying issues. Only the most aware and brave patient will get education on their own.

I teach medical students and their attitudes and habits frustrate me. I have to tell myself, sometimes daily, that more of our students are making an effort than are wanting me to lead them by the hand through medical school, regardless of their own actions.

I am submitting this anonymously because I am not 'supposed' to be frustrated by students who do not appear to want to take responsibility for themselves, much like the patients you described in this post and comments. They are a minority, and I try every day not to let that frustration impair education. Doctor education, patient education - essentially the same.

As I mentioned, I too think that the internet can provide very useful and worthwhile information for patients. But information is not necessarily knowledge. Your forum succeeds in part because of your physician oversight - it lends credibility and support to the endeavor. I am not sure corporately-created sites ever offer the same - most IBM engineers really have no concept of medicine from a physician's perspective, and certainly the sites usually contain disclaimers limiting responsibility of the company involved. Yet those same corporations are more than happy to take a few million of the taxpayer's money. Now I am not anti-capitalist, but our healthcare dollars are finite, and the thought of the Georgian legislature approving this expenditure without thought about its effectiveness or true need is concerning. How many other states will succumb to the same marketing push by Big Business?

Anony 10:03 -

I'm not sure where the "negative comments about patients" occurred in this thread. My intent was NOT to insult or berate patients - on the contrary, I would suggest that when corporations "consume" $5.2 million for a website, the patients are left with very little for the money that is likely to be useful for their healthcare decisions. Maybe I will be proven wrong, but given the number of patients I round on in the hospital that have EVER consulted the web to see if this hospital was right for them, I'd say it's under 10%. Is this a cost-effective plan for that expenditure? Like TBTAM, it seems like plenty of pork to me.

The term may be better called "corporate-driven healthcare." So far, it doesn't seem like the transparency data we're posting on the hospital side is getting much attention from patients either. Even when we post data that they say is relevant to them, like patient satisfaction scores, there is little traffic to justify our efforts. Check out my post about quality at http://socialmediafrenzy.com for the full story.

I don't know if anyone can stop patients -- consumers with attitudes -- from taking charge of their healthcare, especially as employer-paid plans wither and die. With things like Google Health and Microsoft HealthVault, it could get very bad:

The post makes sense. The current situation is far from consumer/patient friendly. It is all about big corporations/insurance companies, drug companies, and huge health organizations.Whenever there is talk about consumer driven health, some commentators argue against the consumer driven healthcare, based on the assumption that people do not want to take responsibility to educate themselves sufficiently to be able to make their own health decisions. This clearly is a huge assumption, based on little data. Fact is, we, (US or the world) never had consumer or market driven healthcare. Never. If you want to call high-deductible insurance plans combined with an HSA or similar attempts in dentistry like http://localdentist4less.com market driven health care, you ain't seen nothing yet. So basically, we never had consumer really make decisions so far. So there is no data. Get seriously started with it, collect your data, and then create opinions. Otherwise its all hot air and keyboard clicking. Also, keep in mind, in a true market driven health care, an average Joe does not need to take care of the health system, just of his own health, and his own choices for healthcare.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.